Detailed Answer
If an insurance adjuster has reduced the emergency room (ER) charges in a personal-injury or accident-related claim, you can often dispute that reduction. In Connecticut, the process begins with information-gathering and goes through insurer appeal steps, regulator complaints, and — if needed — legal action. Below are the practical steps and legal options to challenge a reduced payment.
Step 1 — Learn why the charges were reduced
Ask the insurer (in writing) for a clear explanation of benefits (EOB) or adjustment notice showing exactly why the ER charges were lowered. Common reasons include:
- Services were deemed not medically necessary or not related to the accident
- Coding problems (CPT codes) or charge bundling
- Usual and customary / out‑of‑network rates or negotiated discounts
- Duplicate charges or clerical/billing errors
- Coordination-of-benefits or limits under personal-injury protection (PIP) or medical-payments coverage
Step 2 — Collect supporting documents
Before disputing the reduction, assemble:
- Itemized ER bill(s) and any hospital billing statements
- The insurer’s EOB or denial/adjustment letter
- Medical records, physician notes, and imaging that show the ER visit and why treatment was needed
- Your insurance policy or the claimant’s policy declarations (to confirm coverage types and limits)
- Any police, EMS, or accident reports that link the ER visit to the covered event
Step 3 — Use the insurer’s internal appeal process
Most insurers have a formal internal appeal or reconsideration process. Request a written reconsideration, attach the supporting documents above, and explain why the ER treatment was necessary and properly billed. Keep copies of all communications and note dates and names of representatives.
Step 4 — Correct billing or coding errors
If the reduction was caused by a billing mistake (wrong CPT code, duplicate charge, or provider entry error), ask the provider’s billing office to correct and re-submit the bill to the insurer. A corrected submission often resolves the issue faster than a legal dispute.
Step 5 — Use statutory and regulatory protections
Federal and state laws may offer additional protections. For emergency services, the federal No Surprises Act protects patients from being responsible for out-of-network ER charges beyond normal cost-sharing and creates a dispute resolution process between insurers and providers for out-of-network payment disputes. Learn more from the Centers for Medicare & Medicaid Services: https://www.cms.gov/nosurprises
For Connecticut-specific rules and insurer conduct standards, the Connecticut Insurance Department regulates insurers and handles consumer complaints. If the insurer engaged in unfair claim handling, you can file a complaint with the Department. Visit the Connecticut Insurance Department for consumer help: https://portal.ct.gov/cid
For statutory background on Connecticut insurance law, see Connecticut’s insurance statutes (Title 38a): https://www.cga.ct.gov/current/pub/title_38a.htm
Step 6 — File a complaint with state regulators
If the insurer will not reverse an improper reduction, file a complaint with the Connecticut Insurance Department. Regulators can investigate unfair claim practices and may pressure the insurer to reconsider. Keep a complete record of your appeal attempts and documentation to include with the complaint.
Step 7 — Consider neutral dispute resolution or small claims
If the dispute is between a provider and an insurer over payment levels and informal appeals fail, options include arbitration or neutral dispute resolution where available. If your dispute is with a provider’s billed amount and the amount in controversy is small, Connecticut small-claims court may resolve the matter (check small-claims limits and procedures) — but state regulators and the No Surprises Act may apply first in emergency billing disputes.
Step 8 — When to talk to an attorney
If the insurer still refuses to appropriately pay for ER services that were plainly related to the injury, contact an attorney who handles insurance-claim disputes or personal-injury matters. An attorney can:
- Evaluate whether the insurer breached its contractual or statutory duties
- Represent you in settlement negotiations or litigation
- Help preserve legal rights and meet court deadlines
Timing and statute-of-limitations considerations
Act promptly. Insurance appeals, regulator complaints, and lawsuits have time limits. Preserve records, request the insurer’s appeal process information immediately, and consult counsel early to avoid missed deadlines.
Helpful Hints
- Request an itemized bill and the insurer’s adjustment explanation right away.
- Ask the treating ER physician to provide a short statement tying the ER care to the accident or injury.
- Check whether the No Surprises Act applies — it often protects patients from balance billing for emergency care.
- Correct simple billing errors through the provider’s billing office before escalating.
- Document every call, email, and letter: dates, names, and what was said.
- File a complaint with the Connecticut Insurance Department if the insurer ignores reasonable appeals: https://portal.ct.gov/cid
- Consult a Connecticut attorney if the insurer’s position appears unreasonable or if important deadlines apply.
Disclaimer: This article provides general information about options commonly available in Connecticut for disputing reduced ER charges. It is not legal advice and does not create an attorney-client relationship. For advice about a specific situation, consult a licensed Connecticut attorney or contact the Connecticut Insurance Department for consumer assistance.